EEOICPA BULLETIN NO. 13-01

 

Issue Date:        January 2, 2013

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Effective Date:    January 2, 2013

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Expiration Date:   January 2, 2014

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Subject:  Authorizing Massage Therapy

 

Background:  The Energy Employees Occupational Illness Compensation Program Act (EEOICPA or the Act) provides for medical benefits to covered employees.  Specifically, 42 U.S.C. §7384s(b) and §7385s-8 provide that a covered Part B or Part E employee shall receive medical benefits under §7384t of the EEOICPA.  Section 7384t(a) states:  “The United States shall furnish, to an individual receiving medical benefits under this section for an illness, the services, appliances, and supplies prescribed or recommended by a qualified physician for that illness, which the President considers likely to cure, give relief, or reduce the degree or the period of that illness.” 

 

The Division of Energy Employees Occupational Illness Compensation (DEEOIC) is responsible for ensuring that employees with an accepted illness, under the EEOICPA, receive appropriate and necessary medical care for that illness, as further outlined in this Bulletin.

 

References:  42 U.S.C. §7384s, §7384t, §7385s-8

 

Purpose:  The DEEOIC has determined that certain claimants may require massage therapy, as part of the treatment regimen for their covered medical condition(s).  Stedman’s Medical Dictionary defines “massage” as a method of manipulation of the body or part of the body by rubbing, pinching, kneading, or tapping.[1]  DEEOIC views the possible benefits derived from such massage as: reducing pain and muscle tension; increasing flexibility and range of motion; and improving blood circulation. The purpose of this Bulletin is to provide clarification regarding criteria developed for the management of massage therapy requests.  This Bulletin also identifies and explains the medical evidence that must accompany a request for this type of care.  Lastly, the Bulletin offers procedural guidance to the DEEOIC claims staff, with regard to the review and development process leading up to an authorization or denial of a request for massage therapy services. 

 

Applicability:   All staff.

 

Actions:  

 

1.  All requests for massage therapy require pre-authorization by the Claims Examiner (CE) assigned to the case file.  The claimant, the authorized representative, the treating physician, or a medical service provider may submit massage therapy requests to DEEOIC.  The CE forwards requests for massage therapy to the DEEOIC bill processing agent (BPA) via fax, mail, or electronically for the authorization process to begin.  The CE is to document telephone requests for massage therapy in the phone call section of ECS.  The CE advises any such callers that their request must be in writing for the authorization process to begin, and the CE provides the caller with a verbal description of the medical evidence DEEOIC requires.

 

2.  The BPA creates an electronic record of the request and initiates an electronic communication (referred to as a "thread") to the fiscal officer (FO) at the district office (DO) where the claimant's case file resides.  The thread from the BPA advises the FO of a pending massage therapy request.  Upon receipt of the thread from the BPA, the FO forwards the information to the appropriate CE for review and adjudication.

 

3.  A treating physician must prescribe massage therapy for the claimant for the treatment or care of a covered medical condition(s).  Accompanying the prescription, the physician is to include a letter of medical necessity reflecting that an initial face-to-face visit was held with the claimant.  (Face-to-face visits are only required for the initial pre-authorization request.)  The narrative should describe the unique physical and therapeutic benefits that the claimant will derive from massage therapy, and specify the frequency and duration of care to be provided in allotments of time (e.g., twice a week for eight weeks).   

 

4.  When the CE receives a massage therapy request that is unaccompanied by an appropriate letter of medical necessity or rationale, the CE begins development.  The CE sends a letter to the claimant advising that the district office has received a request for massage therapy, but without the required supporting medical documentation or rationale.  The development letter to the claimant describes the medical documentation needed to support the request, asks for the name of the licensed/certified massage therapy provider, and grants the claimant 30 calendar days to provide the requested information.  The CE also notifies the claimant that a lack of response or submission of insufficient evidence or rationale will result in a denial of the request.  The CE documents this request through correspondence created in ECS. 

 

5.  If the CE receives the appropriate medical evidence within the 30-day development period, the CE prepares a letter to the claimant authorizing massage therapy.  The CE sends a copy of the approval letter to the provider designated by the claimant to provide the service.  The approval letter must contain the following information:

 

(a)         Covered medical condition(s) for which massage therapy is to treat.

 

(b)         Number and frequency of visits approved (i.e., 2 visits per week for 8 weeks).

 

(c)         Authorized billing code(s) relevant to the approval.

 

(d)         Time period (dates) during which the services are authorized.

 

(e)         Requirement to send medical notes to match each service date

 

(f)         Statement advising that fees are subject to the OWCP fee schedule.

 

6.  The initial authorization period may be fewer than, but should not exceed 8 weeks, and the CE may approve up to 2 visits per week, for a total of 16 visits during the initial authorization period.  Each visit is equal to a maximum of 1.5 hours.  Reauthorization, including obtaining updated medical evidence, is required for any request for additional massage therapy after the initial 8-week period.  The CE may not authorize more than 60 massage therapy visits per calendar year.

 

7.  Upon completion of the approval, the CE sends an email to the FO, who prepares and sends a thread to the BPA, authorizing the services approved by the CE.  The CE also documents the approval for massage therapy in the Notes section of ECS.

 

8.  If, at the end of the initial 8-week authorization period, the CE receives a new request for additional massage therapy, the CE must conduct a new evaluation of the medical necessity for continuation of care.  If the request is appropriate (updated medical documentation adequately explains the medical necessity for continuing massage therapy), the CE grants authorization for the extension of care within the authorization parameters of no more than two visits per week and a maximum of 60 visits per year.

 

9.  Massage therapy providers, which include a relative of the claimant, must hold a valid massage therapist’s license or certification in the state where services are rendered. 

 

10. Massage therapy services must be conducted in an appropriate setting (i.e., medical clinic, medical office, etc.) and should be billed daily (i.e., one date of service (DOS) per OWCP-1500 line).  The service provider must submit medical notes to the DEEOIC’s BPA, along with their bill, describing the particular therapeutic care provided during each visit with the claimant. The notes should describe the effect of the massage therapy, including any specific improvements in functionality or in achieving relief from the symptoms of a compensable illness.  The BPA then forwards the medical notes to the district office for review.  Authorized billing codes for massage therapy are CPT codes 97124 and 97140 as reflected in Attachment 1.  The OWCP fee schedule does not provide a separate allowance for massage therapy supplies (i.e., tables, equipment, etc.).  The cost of supplies is factored into the fee schedule amount.  

 

11. If the CE receives a request for in-home massage therapy, the claimant must be homebound in order to receive such authorization.  Medical evidence from the treating physician must demonstrate that the claimant is medically unable to travel to obtain massage therapy.  Once the CE receives convincing evidence that the claimant is not able to travel for care, and sufficient documentation exists regarding the medical necessity for care, the CE may authorize in-home massage therapy.

 

12. Massage therapy is not restricted by medical diagnosis or condition, but is not appropriate when prescribed solely for prevention of future injury, recreation (spa therapy), and/or stress reduction. 

 

13. If, after 30 days from development, and upon review of the evidence, the CE determines there is insufficient evidence to warrant either initial authorization or reauthorization of continuing massage therapy, the CE sends a letter-decision to the claimant.  The letter decision is to include a narrative explanation as to why the evidence is insufficient to warrant authorization.  The CE is to send a copy of the letter decision to the provider, if applicable.  The letter-decision must include the following language:

 

If you disagree with this decision and wish to request a formal decision, please immediately advise this office, in writing, that you wish to have a Recommended Decision issued in this case, providing you with your rights of action.

 

Any request for massage therapy beyond 60 visits in one calendar year should be denied without development, citing this Bulletin.

 

14. Upon completion and mailing of the letter, the CE sends an email to the FO denying the request for massage therapy.  The FO then transmits this information via thread to the BPA.

 

15. Should the claimant request a recommended decision (RD), regarding denial of either the initial authorization or recertification of massage therapy, the CE completes the RD process in accordance with existing DEEOIC procedure. Likewise, the Final Adjudication Branch (FAB) issues an appropriate decision following the issuance of the RD.

 

Disposition:  Retain until incorporated in the Federal (EEOICPA) Procedure Manual.

 

 

 

RACHEL P. LEITON

Director, Division of Energy Employees

Occupational Illness Compensation

 

 

Attachment

 

 

Distribution List No. 1:  Claims Examiners, Supervisory Claims Examiners, Technical Assistants, Customer Service Representatives, Fiscal Officers, FAB District Managers, Operation Chiefs, Hearing Representatives, and District Office Mail & File Sections

 



[1] Stedman’s Medical Dictionary, 28th Edition (2006)